American healthcare faces a difficult challenge - improve quality and eliminate disparities while containing costs. Many physicians, policymakers and employers are optimistic that performance incentives - in the form of pay-for-performance and public reporting -- will help improve the quality of American healthcare. Despite the proliferation of these programs, there is little evidence that they produce their intended results, and significant data suggests that they can create negative unintended consequences. In this study proposal, we hypothesize that performance incentives can significantly improve incentivized components of care, but will have a null or negative effect on unincentivized components of care. To examine these questions, we will use a retrospective study design and draw independent samples at three strategically chosen cross-sections in time before and after the introduction of performance incentives at our nation's largest federally-qualified health center, ACCESS Community Health Network. To help account for secular trends that cannot otherwise be addressed in a pre- and post-intervention design, we will compare changes in the care provided to trends in the overall case-mix of patients at ACCESS during the study period. The proposed study will provide a novel contribution to the fields of healthcare quality and equity, as well as to the general literature on incentives. It will develop our methods for empirically evaluating the intended and unintended impact of organizational interventions, provide insight into the effect of penalties in performance incentive programs, yield foundational information on the effect of physician-level incentives. and be the first rigorous empirical evaluation of the use of performance incentives in the Community Health Center setting. The ideal candidate for this line of inquiry must demonstrate aptitude and experience in underserved communities, clinical medicine, and policy-relevant research that draws on interdisciplinary resources. Dr. Chien is that candidate - she has extensive 'hands on'experience working with vulnerable populations. is a practicing general pediatrician, and is a recent alumnus of the Robert Wood Johnson Clinical Scholars program with a track record of research that draws upon the disciplines of medicine, public policy and economics. This career development award is critical for Dr. Chien to further develop the skills and experience necessary to become a nationally respected health services researcher who examines policy-relevant issues related to the use of performance incentives in healthcare, particularly as it pertains to the care delivered to minorities, the medically complex, and the socially disadvantaged.